Tools available to encourage discussions about end-of-life care

MOH's Reply

Tools available to encourage discussions about end-of-life care

We thank Ms Candice Yeo, Mr Jeffrey Law Lee Beng and Mr Cheng Choon Fei for their letters on end-of-life planning (Drive home importance of advance care planning; Speaking openly will help families avoid disputes; and Remove some of the barriers to end-of-life planning, all July 16).

We agree that conversations surrounding end-of-life matters are becoming increasingly important as our society ages.

However, cultural and social barriers often make it difficult for family members to start such conversations.

To encourage discussions on palliative care and end-of-life matters, the Ministry of Health (MOH) has partnered the Singapore Hospice Council (SHC) for a three-year public education campaign called Live Well. Leave Well.

An important part of end-of-life planning is advance care planning (ACP), which allows individuals to express their future care preferences and plan ahead, in the event that they are seriously ill and unable to make their own decisions.

These conversations focus on the individual's personal values, beliefs and goals for care which may affect his future care preferences.

We encourage Singaporeans to start ACP discussions earlier when they are healthier, as it empowers them to choose how they would like to be cared for, even in their final days.

Moreover, making an ACP reduces the uncertainty, stress and anxiety for our loved ones in difficult times when they have to make decisions on our behalf.

MOH has worked with the Agency for Integrated Care and SHC to develop conversation and community-engagement tools to help care-providers and individuals initiate these ACP discussions.

We also encourage Singaporeans to make use of ACP touchpoints in the community, such as selected senior activity centres and polyclinics to facilitate such discussions (for details, visit www.livingmatters.sg/ACP-Directory/). We are also in the process of placing resources related to end-of-life information and services from various sources, including ACP, into a single digital portal for convenience.

About 4,500 ACPs were completed last year, more than double the number in 2015.

The MOH will continue to work with our partners to encourage conversations on end-of-life care.

Titus Lee

Director, Aged Care Services

Ministry of Health

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Forum Letters

Remove some of the barriers to end-of-life planning

Before we can have better end-of-life planning, we should first remove the barriers (Report urges better end-of-life planning, July 13 ↗ (opens in new tab)).

Families are usually informed about the patient's deteriorating medical condition each time he is admitted, but families may not understand that the repeated admissions are a sign of imminent death.

This is because in times of stress, families cannot think straight. There are also doctors and nurses who believe their basic training does not prepare them to deal with terminal illnesses.

Moreover, there are just too few palliative care specialists.

These factors are barriers to good end-of-life planning.

Doctors and nurses must, despite stigma, superstition and discomfort, have the skills to talk to patients about death and dying.

Family members may also not know what level of care the patient would prefer, and end up allowing more medical interventions than the patient or even they would want.

Disputes within a family over end-of-life care may end up leaving provision of care at the default "all necessary care" setting, which could lead to interventions such as ventilators or feeding tubes, when these would be medically futile.

Some families may find removing life support to be more difficult than declining it, especially when the patient did not sign an advance medical directive.

Because death is such a personal experience and each individual's fears and ideals about it are so specific, it would be impossible to create a one-size-fits-all answer to how care should be provided.

Having an advance medical directive has benefits, but it may be misunderstood and its usefulness is limited in scope. Some people fear that an advance directive interferes with adequate care. In one sense, the directive cannot contemplate every possibility.

Appointing a healthcare proxy, an agent who makes healthcare decisions on the patient's behalf, is efficient but the patient may not receive the care he wants.

A better approach to planning for the end of life is needed. Talking about death or dying can bring up many uncomfortable thoughts and feelings, so wanting to avoid it is a common reaction.

But talking about death, especially with someone who has a terminal illness, can be helpful at any stage in the illness.

Cheng Choon Fei

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Speaking openly will help families avoid disputes

It is good to have workshops on living and dying well, such as those organised by local charity Both Sides, Now (Kick-starting talk on death and dying early, July 13 ↗ (opens in new tab)).

To have peace of mind, parents would do well to let their children know what they would like done should they fall ill, become disabled, or worse still, have life-threatening conditions.

While most find these topics morbid, it can only be a good thing when family members are able to discuss the future in relation to these contingencies.

As it is difficult to predict one's family situation in the years to come, discussing old-age plans with loved ones is crucial.

Some of the elderly may desire to die at home, where they need the love and care of family members around them, and, most importantly, where they will feel comfortable in familiar surroundings.

Others may choose to spend their last days in a hospital so that they are not such a burden on family members or friends.

Making their last wishes known to their children will facilitate better understanding and cooperation among loved ones in terms of family support, medical treatment and also funeral arrangements.

Above all, unnecessary misunderstandings and family disputes are unlikely to arise.

Jeffrey Law Lee Beng

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Drive home importance of advance care planning

In Singapore, death is still a taboo topic for many, especially among the elderly. However, given the fast ageing society, we should consider issues regarding the elderly more urgently (Report urges better end-of-life planning, July 13 ↗ (opens in new tab)).

One good way is to popularise advance care planning (ACP).

As end-of-life care is usually related to a person's religious beliefs, it is apt for religious organisations to take the lead to explain and start the discussion with their members.

Trained ACP facilitators can help reach out to people at places of worship. For those who do not belong to a religious group, community centres would be a good alternative.

We could also increase awareness and generate widespread publicity with more ads.

People will also have more time to think through ACP issues in a relaxed environment.

Decentralising ACP to the community can reduce the heavy workload on nurses and relieve them to perform other nursing care duties. Good advance care planning can lead to calm in times of distress, and also lead to better use of resources.

Singapore is blessed with advanced medical technologies. Often, a person diagnosed with a terminal illness can still live for many more years, but in a state of suffering.

People would benefit from being more educated about quality of life and palliative care.

As a healthcare worker, I often come across the elderly who are fed via a tube, which in most cases, serves merely a life-sustaining purpose. Some do not even have any relatives who visit them.

These patients cannot now choose what they want to do with their lives. If better planning had been done earlier, such suffering might have been alleviated.

Candice Yeo Chay Hoon